At 4:30 on a Friday afternoon, Fabiola walked in to see her last scheduled patient. She had worked every day that week and all through the previous weekend. She was tired and looked forward to sitting on her couch with a bowl of pasta, a glass of red wine and her snuggly cat.
If all went well, this final appointment of the day would be quick and routine. Nothing too exciting, nothing too draining. But it had been her experience over the years that in medicine, the moment you have that thought on a Friday afternoon is when everything goes awry.
Fabiola introduced herself to a lovely and pleasant 22-year-old woman. Her name was Antonia Padilla. She had straight black hair that fell long past her shoulders, parted in the middle, and a wide smile. She wore a pink, flowery blouse. A sheet covered the lower half of her body. She was cheery, bubbly and light-hearted—the type of person with whom anyone could enjoy an extended conversation. Fabiola could easily see herself being friends with her had they met at a dinner party or the gym. Antonia talked about going out to dinner that night with her boyfriend at their favorite Thai restaurant. She then began to tell Fabiola about the unusual bleeding patterns she had developed over the past couple of months.
To Fabiola, it sounded like typical bleeding with an IUD. She explained to Antonia that depending on what type of IUD they have, women can develop heavier periods or unpredictable spotting. However, just to be sure, she would have to conduct a routine pelvic exam.
Even though it was routine, whenever Fabiola had to do a women’s health exam, she felt like she was rearranging furniture in a house. Everything had to be repositioned.
She raised the table, positioned the stirrups and biohazard bucket, then set up the patient and herself. She had to remind herself, Don’t touch the curtain. The dull-colored curtain right at her back was meant to provide comfort and privacy for the patient. For Fabiola it was just a nuisance, like a mosquito buzzing in her ear. The polyester rubbed against her white coat and felt like a grater reaching for her skin. She often wondered, Do other professions have these difficulties, these annoyances, just for their routine work?
She inserted the speculum and was puzzled to find more blood than expected. Then, she was even more surprised not to see the IUD strings at the cervical opening.
I will have to do an ultrasound now, she thought to herself. This would likely be time consuming, because the ultrasound machine was never where it needed to be. Very often, her assistant would have to go to the first floor to pry it out of the other provider’s hands, who shouldn’t be using it in the first place because it was purchased exclusively for the gynecology department.
She found in her line of work, when you need something important, it is rarely easy to get. There was always a layer to break through.
This time, though, to her surprise, the ultrasound machine was available on the second floor and ready to go within seven minutes. I love my assistant today, she thought to herself. She is the best! Things always move more smoothly when an assistant and provider click. This relationship develops over time, day in and day out, over months of building trust. Fabiola thought, Having a great assistant makes it all worthwhile.
They wheeled the bulky ultrasound machine into the exam room. They had to cram it into an already-tight space along with three people, an exam table, a sink, a chair, a stool and a computer. Somehow it magically always fit.
After putting gloves on and lathering the probe with gel, she began the intravaginal ultrasound. She searched for the IUD in her patient’s uterus, so that she could reassure her. However, once the probe was in position, instead of the IUD, she saw a large moving fetus.
Surprised, Fabiola removed the ultrasound probe and began to explain to the patient that there was an unexpected finding: a pregnancy in her uterus.
Antonia’s eyes became still and she gasped. “What?!”
“Yes, you are pregnant,” Fabiola replied gently but firmly. “When you’re ready I can take a few measurements to determine how far along you are.”
“I’m ready,” she said. She looked frightened.
Fabiola tried to measure as quickly as she could. The measurements indicated she was 10 weeks and 5 days pregnant. Holy shit, she thought to herself. She tried hard not to show any reactions on her face.
She told her the fetus’s approximate gestational age, and Antonia began to cry. Large tears streamed out of her brown eyes and stained her cheeks with mascara. Fabiola’s heart went out to her. She tried to comfort her by sitting with her as she handed her a tissue. She spoke to her kindly and tried to gently explain her options.
Fabiola was reminded of when she learned about her own pregnancy. Although it was planned, it was still scary. Being pregnant can be terrifying.
Even worse, this woman had taken the necessary precautions. She had taken the initiative and committed herself to having a device inserted into her uterus. This is often not an easy decision to make. She now had to accept that her method failed her. She was in the 1% of women who get pregnant with an IUD. She now needed to make choices she was hoping not to ever have to make.
Fabiola wanted to make sure her patient was as comfortable as possible, so she told her she would let her get dressed. She would return in a few minutes to further discuss her options. She stepped into the empty halls. It was now past 6 PM, more than an hour after her shift was supposed to end. As she walked into her office and looked out of the wide windows, she saw orange, pink and purple hues of the setting sun. She took a deep breath and let out a soft sigh. She called the gynecologist on duty to make sure they were on the same page with Antonia’s case.
As a physician assistant, Fabiola relied on this colleague as a sounding board for her concerns and ideas. The fact that the gynecologist at her facility was amazing was priceless. She was loved by all patients. She was loved by her colleagues. She was kind, warm and intelligent. Fabiola wasn’t surprised when the phone rang once and she answered immediately and said, “What’s up?” Fabiola hardly ever called her for anything. They talked about the management options.
The conversation set Fabiola’s mind at ease, and she returned to the exam room to further comfort her young patient. Her bubbliness had faded and was now replaced by tears.
As they talked about her options, Antonia said to Fabiola, “‘I’m lucky I’m not in Texas.” Fabiola agreed. She thought about all the difficulties women experience. There were so many issues with reproductive rights coupled with the challenges of having a uterus. She had just witnessed the agony someone faces when their contraception fails. Despite being responsible, nature intervened and threw a wrench in this young woman’s plans. She thought, How do women manage to gracefully deal with it all? They are a miracle.
Fabiola told her she didn’t have to make any decisions today. “It’s Friday evening,” she reminded her, “nothing is going to happen over the weekend. Take some time to think about what you would like to do. We’ll have another visit on Monday.”
She gave her ER precautions in case she began to bleed more heavily, developed severe cramps or had a fever. The patient thanked her at the end. She was now calm and had stopped crying, at least for the moment. Fabiola guessed she would break down when she got into her partner’s arms.
Later she thought to herself, My years of experience served me well at this moment. She had been able to provide Antonia with the information, comfort and support she needed. Although the beginning of her weekend had been delayed, she didn’t mind. This was the nature of the work; this is what it was all about with a life in medicine. It was most important to provide the care that is required and needed.
When Fabiola finally got home that night, she showered, heated up pasta with a meaty marinara sauce. Then she curled up on her favorite corner of the couch with her cat and journal. She opened it and wrote:
A life in medicine is a life of constant sacrifice. As providers we sacrifice our sleep and time away from families. We worry about our patients. We wonder if they are feeling better, we worry if their fever has resolved. Did I make the right diagnosis? These are all constant struggles and challenges we battle daily and gracefully. When you agree to being a medical provider, you take on a burden. You commit to carrying this burden throughout your career. It’s not only because of the sacrifices that are made, but the hardships you experience alongside the patient. My mother as a nurse and my father as a doctor often said, “es mucho sacrificio”. “It’s too much sacrifice.”
